A nurse in the emergency department is caring for a 52-year-old male client experiencing chest pain. Below are the exhibits to guide your answer:
Complete the diagram by dragging from the choices below to specify:
- The condition the client is most likely experiencing.
- Two actions the nurse should take.
- Two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Condition: Myocardial infarction.
2 actions:
Administer oxygen via nasal cannula 2 L/min,
Request a prescription for aspirin 325 mg.
2 parameters:
Vital signs,
Electrocardiogram (ECG) rhythm.
Rationale for correct condition: A myocardial infarction is indicated by the elevated troponin levels and ST elevation on the ECG. The client’s symptoms of chest pain, elevated heart rate, and low oxygen saturation support this diagnosis. Prompt identification and treatment are crucial to minimize heart damage. The medical history of hypertension and coronary artery disease increases the likelihood. Immediate interventions can significantly improve outcomes.
Rationale for actions: Administer oxygen to improve oxygenation and reduce myocardial workload. Requesting aspirin helps prevent further clot formation. Morphine alleviates pain but may obscure symptoms, making it less urgent. Nitroglycerin relieves chest pain by vasodilation but is secondary. Verapamil is less immediate for acute myocardial infarction management. Vital signs reflect hemodynamic status and response to treatment. ECG rhythm detects ongoing ischemia or arrhythmias. Monitoring WBC count is less relevant acutely. Platelet count is stable; not the focus in immediate management.
Rationale for parameters: Vital signs ensure hemodynamic stability and detect hypotension or shock. ECG rhythm monitors arrhythmias and ongoing ischemia, critical in myocardial infarction. WBC count indicates infection or inflammation, less immediate concern. Platelet count is important for bleeding risks but less immediate. Chronic stable angina presents with predictable, non-severe pain. Ischemic stroke symptoms differ; focus on neurological deficits. Cardiogenic shock would present with more severe hypotension and signs of organ failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The inability to locate a dorsalis pedis pulse and increasing pain indicate compromised circulation, which requires immediate attention to prevent complications.
Choice B rationale
Pain relieved after administering medication indicates effective pain management, which is not an urgent issue to report immediately.
Choice C rationale
Generalized weakness and increasing sensitivity to touch can be concerning but are not as urgent as signs of compromised circulation.
Choice D rationale
Localized edema and discoloration are expected findings in a fracture and are not as urgent as an absent pulse. .
Correct Answer is C
Explanation
Choice A rationale
Administering insulin when the breakfast tray arrives may not provide sufficient time for the insulin to take effect before the client begins eating, potentially leading to hyperglycemia.
Choice B rationale
Administering insulin at 07: is too early and may result in hypoglycemia before the client eats breakfast.
Choice C rationale
Administering insulin at 07: allows sufficient time for the insulin to take effect before the client eats breakfast, helping to maintain appropriate blood glucose levels.
Choice D rationale
Administering insulin 30 minutes after breakfast is too late and could result in hyperglycemia since the client would have already consumed carbohydrates.
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